**19. Approaches to treatment**

**1.** Staged approach: Advocates of a staged procedure perform CEA several days prior to CABG or several weeks following cardiac surgery. The rationale of the staged procedure is to decrease the risk of stroke in the cardiac procedure and eliminate the need for longer and more stressful combined procedure. Increased cardiac morbidity and mortality resulting from CEA may offset potential benefits of this approach.[42]

In those with a history of TIA or stroke who have a significant carotid artery stenosis (50% to 99% in men or 70% to 99% in women), the likelihood of a post-CABG stroke is high; as a result, they are likely to benefit from carotid revascularization. Conversely, CABG alone can be performed safely in patients with asymptomatic unilateral carotid stenoses, because a carotid revascularization procedure offers no discernible reduction in the incidence of stroke or death in these individuals. Men with asymptomatic bilateral severe carotid stenoses (50% to 99%) or a unilateral severe stenosis in conjunction with a contralateral carotid artery occlusion may be considered for carotid revascularization in conjunction with CABG. Little evidence exists to suggest that women with asymptomatic carotid artery disease benefit from carotid revascu‐ larization in conjunction with CABG. Whether the carotid and coronary revascularization procedures are performed simultaneously or in a staged, sequential fashion is usually dictated by the presence or absence of certain clinical variables. In general, synchronous combined procedures are performed only in those with both cerebrovascular symptoms and ACS.[44]

**2.** Combined approach: performing CEA and CABG in the same setting: If the combined approach can be done safely, a second surgical procedure and hospital stay may be eliminated, with significant cost reduction. Long-term stroke free survival may also be significantly improved.[42] The problem with this approach is that the stroke rate is exceedingly high.

**3.** Ignoring the carotid disease initially and addressing it weeks to months later after the CABG procedure may be another approach. This idea is supported by a retrospective review of 94 patients with asymptomatic high-grade carotid stenosis undergoing CABG. There was one perioperative stroke and no deaths in this group of patients. These data combined with findings of Naylor et al that prophylactic CEA could barely prevent < 40% of post-CABG strokes [43] would support this approach in asymptomatic carotid stenoses. In the absence of clear guidelines, the decision is better individualized dealing with the more symptomatic vascular bed first. The simultaneous performance of CABG and CEA carries a high risk but is warranted in patients with recent symptoms of both severe coronary disease (unstable angina) and severe carotid stenosis.

Carotid stenting can be an alternative in endarterectomy in this subset of patients.[45, 46] A recent Comparison of Early and Late Outcomes with Three Approaches to Carotid Revascu‐ larization and Open Heart Surgery showed that Staged CAS-OHS and combined CEA-OHS are associated with similar risk of death, stroke or MI in the short term, with both being better than staged CEA-OHS. However, the outcomes are significantly in favor of staged CAS-OHS after the first year.[47]
